[French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]

OBJECTIVES

The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations.

METHODOLOGY

To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS).

RESULTS

The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey.

CONCLUSION

All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.

[Pyogenic streptococcal omphalitis and foot's cellulitis in an 11 day old infant]

Omphalitis is a rare infection in our countries. Streptoccus pyogenes is one of the most frequently encountered germs. Complications are rare but include septicemia and necrotizing fasciitis with a high mortality rate. The case reported in this article is that of an 11 days old infant with pyogenic streptococcal omphalitis who developed cellulitis of left food. An intravenous antibiotic treatment allowed complete resolution of the symptoms. The article is the opportunity to review of the risk factors of this affection, its complications and treatments.

Epidemiology, prognosis and treatment of simultaneous squamous cell carcinomas of the oral cavity and hypopharynx

OBJECTIVE

The study was designed to assess the prevalence, management and survival of patients with simultaneous squamous cell carcinomas of the oral cavity and hypopharynx (OC/HP).

MATERIAL AND METHODS

A multicenter, retrospective study (2 university hospitals) was conducted between 2003 and 2007 on a series of 96 patients with simultaneous squamous cell cancers of the OC/HP.

RESULTS

A total of 88 men and 8 women were included in the study: 81 patients presented double sites, 14 presented triple sites and one presented quadruple sites. The tumour sites most frequently observed were: hypopharynx in 61% of cases (involving the pyriform sinus in 42% of cases) and the oropharynx in 59% of cases (involving the palatine tonsil in 30% of cases). Upper aerodigestive tract endoscopy under general anaesthesia revealed a simultaneous lesion not suspected on clinical examination in 45% of patients: the site discovered on endoscopy was hypopharyngeal in 2 out of 3 cases; the tumour was classified T1 or T2 in 95.5% of cases. Patients treated simultaneously for all sites had a better prognosis than patients in whom each tumour was treated separately. The 5-year specific survival was 34% and the 5-year overall survival was 28%.

CONCLUSION

The prevalence of simultaneous squamous cell carcinomas of the oral cavity and hypopharynx ranges between 1 to 7.4% in the literature and was 4.6% in the present series. A common treatment strategy for each of the patient's tumours appears to be superior to the current theoretical approach that consists of considering each tumour separately.

'Aggressive papillary' thyroid microcarcinoma

The objective of this study is to highlight the fact that papillary thyroid microcarcinoma can be aggressive, requiring therapeutic management similar to that of other differentiated thyroid cancers. This 8-year retrospective study concerned 187 surgical patients managed in an ENT and Head and Neck surgery department for thyroid cancer. 65 patients were found to have papillary microcarcinoma. 41 microcarcinomas were considered to be aggressive because of the presence of several risk factors such as larger than 5 mm, multifocal microcarcinomas, capsular effraction, vascular embolus, tumour extension beyond the thyroid parenchyma and metastatic lymphadenopathy. All patients with aggressive papillary microcarcinoma were treated by total thyroidectomy and (131)I. Ipsilateral recurrent laryngeal and lateral cervical lymph node dissections were performed in ten patients, ipsilateral cervical lymph node dissection was performed in six patients and bilateral recurrent laryngeal and lateral cervical lymph node dissections were performed in three patients. No recurrence or metastasis was observed (follow-up ranging from 6 months to 8 years). The optimal management of thyroid papillary microcarcinoma is still controversial. "Aggressive" papillary thyroid microcarcinoma is not rare and may justify aggressive treatment depending on the presence or absence of prognostic risk factors.

[Persistence of pulmonary lesions in a 6-year-old boy with type I Gaucher's disease treated by alglucerase since the age of 20 months]

BACKGROUND

Gaucher's disease is a serious disorder which becomes curable by bone marrow transplantation. Enzyme replacement therapy has permitted improvement in quality of life and has been shown to decrease the disease's progression.

OBSERVATION

A 6-year-old boy was treated by alglucerase (Ceredase) since the age of 20 months. He presented at that time a failure to thrive, pancytopenia, hepatosplenomegaly and bone involvement. The lung X-rays revealed a diffuse reticulonodular pattern. After 4 years and 5 months, there was an improvement of growth and hepatosplenomegaly, associated with hematological parameters and bone changes normalization. However, an important interstitial syndrome without clinical signs persisted.

CONCLUSION

In our patient it is impossible to note the difference between pulmonary disease from fibrotic origin and pulmonary involvement by Gaucher's cells accumulation.

Life-threatening fish allergy successfully treated with immunotherapy

Manifestations of fish allergy can include near-fatal anaphylactic reaction. In very sensitive patients, fish odors and cooking vapors may have some allergenic activity. We reported a case of life-threatening fish allergy in a girl of 39 months referred for three episodes of Quincke edema with wheezing, cyanosis and severe urticaria after fish consumption or inhalation. Reagins were found against codfish and direct skin prick test with fresh food (codfish) showed important local reaction. Strict avoidance of fish in the diet is usually the only recommended procedure. However, in this particular case, the life-threatening nature of the allergic reaction was the major consideration to perform a desensitization. The child was treated by RUSH immunotherapy using codfish extracts from BENCARD company, following the schedule for insect venom allergy described by Pharmacia. Immunotherapy was performed immediately after determination of the threshold of sensitivity by specific skin prick tests and intra-dermal injections. Desensitization was initiated with a 1/10 dilution of the cut-off solution and 5 subcutaneous injections were administered daily. When important local reactions were observed, additional doses were necessary to obtain tolerance. After the RUSH therapy, the child was submitted to uncooked codfish odors without any reaction. No reaction has been observed even when the child has accidentally eaten a little piece of codfish.

[Asthma and recurrent respiratory infections in children]

Recurrent respiratory infections in children are usually associated with a bronchial hyperreactivity not diagnosed or insufficiently treated. Determining the trigger factors of asthma in a child (allergy, gastro-esophageal reflux or exercise induced-asthma) is as important as avoiding passive tobacco smoking. Through knowledge of the disease and its appropriate treatment, the patient must become asymptomatic.

Atopic dermatitis: role of food and house dust mite allergens

OBJECTIVE

The aim of this study was to evaluate the humoral immune response to cow milk (CM) protein, soya protein, and house dust mites in a group of 64 CM-fed infants, who had atopic dermatitis as the sole atopic manifestation, by measuring not only IgE but also specific IgG antibodies (Ab) against bovine beta-lactoglobulin, soya flour aqueous extracts, and Der P1 antigens.

METHODS

A CM-free diet (Nan HA, Nestle) was given to these 64 CM-fed infants and the sensitivity to CM proteins was established by a positive challenge test with the offending food in improved infants. The serum was obtained just before the start of the CM-free diet, at the first consultation. The patients were classified into two groups according to their clinical response to the hypoallergenic formula.

RESULTS

Thirty-one infants (group 1) improved dramatically (positive challenge test), and 33 (group 2) did not improve with the exclusion diet but did improve after eviction of dust-producing items in the environment. The two groups were different in terms of their total IgE immunoglobulin concentration (higher in group 1, P < .05) and concentration of specific IgE Ab against CM protein (more frequent in group 1, P < .01). The IgG Ab concentrations against beta-lactoglobulin, the major CM antigen (P < 10-4), and against soya protein (P < .01) were significantly more elevated in the group improved by the diet, with a threshold above which the response to the exclusion diet could be predicted as positive. On the contrary, the level of specific IgG Ab against house dust mites was four times higher in group 2 than in group 1. Twenty-nine of the 33 infants of group 2 improved after eviction of dust-producing items in the environment.

CONCLUSIONS

It is proposed that specific IgG Ab concentrations against beta-lactoglobulin, soya protein, and Der P1 antigen be determined in infants and children suffering from atopic dermatitis as a means of predicting the response to an exclusion diet, and a possible role of house dust mites in the pathogenicity of the disease is suggested.

Maternal immune status against beta-lactoglobulin and cow milk allergy in the infant

Beta-lactoglobulin (BLG) is probably the major cow milk antigen. Serum levels of anti-BLG antibodies were determined prospectively in mothers. The results were analyzed according to the existence of allergic manifestations in infants during the first months of life. Mothers of babies who developed allergy had statistically lower IgG anti-BLG concentrations than mothers of infants who presented no symptoms (P less than .001). Together with IgE umbilical cord blood screening, determine maternal IgG anti-BLG concentrations can more clearly define the allergic risk in the infant.